Radiographic findings after breast augmentation by autologous fat transfer

Autologous Fat Grafting in Breast Augmentation: A Systematic Review Highlighting the Need for Clinical Caution

BACKGROUND

Autologous fat grafting (AFG) is a breast augmentation method for treating volume and contour abnormalities. This systematic review aims to summarize complications, radiologic safety, volume retention, and patient satisfaction associated with AFG.

METHODS

The PubMed, Embase, Google Scholar, Cochrane Central Register of Controlled Trials, Wiley library, clinical key/Elsevier, and EBSCO databases were searched for relevant studies from January of 2009 to March of 2022. Articles describing AFG for breast augmentation were selected based on predetermined inclusion and exclusion criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were adhered to, and the study was registered on the International Prospective Register of Systematic Reviews. The Risk of Bias in Nonrandomized Studies of Interventions assessment was used to assess the quality of studies and the risk of bias was measured using the Cochrane Risk of Bias Assessment Tool for Nonrandomized Studies of Interventions.

RESULTS

A total of 35 studies comprising 3757 women were included. The average follow-up duration was 24.5 months (range, 1 to 372 months). The overall complication rate was 27.8%, with fat necrosis making up 43.7% of all complications. Average fat volume injected was 300 mL (range, 134 to 610 mL), and average volume retention was 58% (range, 44% to 83%). Volume retention was greater with supplementation of fat with platelet-rich plasma and stromal vascular fraction. The most common radiologic changes were fat necrosis (9.4%) and calcification (1.2%). After 1 year of follow-up, patient satisfaction was, on average, 92% (range, 83.2% to 97.5%). The included studies were of good quality and consisted of a moderate risk of bias.

CONCLUSIONS

AFG was associated with an overall complication rate of 27.8%. Additional supplementation of fat with platelet-rich plasma and stromal vascular fraction may improve graft survival. Despite poor volume retention being a persistent drawback, patient satisfaction remains high.

Fat Grafting to the Breast for Aesthetic Indications: Techniques and Outcomes in 165 Consecutive Patients

PURPOSE

Fat grafting to the breast for aesthetic indications has become increasingly popular. Herein, methods, aesthetic outcomes, and complications are reviewed in a retrospective case series.

METHODS

Female patients (n=165) with an average age of 45 years (range: 17-78 years) who underwent fat grafting to breast were evaluated. Demographic parameters, the type of procedure, the amount of fat transferred, the site(s) of fat harvest, operative times, and the patient's postoperative recovery and outcomes were recorded.

RESULTS

Of the 165 patients, 105 had breast augmentation with fat only. Of these 105 patients, 14(8%) had implant removal with and without capsulectomy, and 61(37%) had mastopexies. Composite augmentation was performed in the remaining 60 patients. The average amount of fat used was 208 cc (range: 10 to 945 cc) per breast. Forty-five patients (27%) underwent a second procedure. Of the 165 patients, 37(22%) had adverse events unrelated to the fat graft, including suture abscesses, scarring, and minor incision cite skin breakdown. Four patients (2.4%) had a complication related to fat grafting including 'lump' formation between the breast, abnormal mammograms, and the need for simple aspiration of a lipid cyst.

CONCLUSIONS

Autologous fat grafting should be considered for both primary and secondary aesthetic breast surgery to enhance outcomes. Complications related to fat grafting are uncommon. Revisional and secondary surgeries may be needed to achieve the desired outcome. Power-assisted liposuction, with vibratory infiltration of the tumescent solution, auto-infusion of fat, and Expansion Vibration Lipofilling using a closed system has become our preferred technique. Fat grafting to breast can be considered for both primary and secondary aesthetic breast surgery Complications related to fat grafting are uncommon There does not appear to be an overall increase in complications of associated mastopexy and composite augmentation LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Lipomodeling for congenital breast deformities: Technique, results and indications]

Congenital breast deformities usually occur during adolescence and can disturb the self-development and affect the identity during this crucial stage. Several surgical techniques are now available to correct these different anomalies. The objective is to clarify the place of lipomodeling in thoraco-mammary malformations, resuming the different indications, the results, as well as the limits and potential complications. The adipose tissue was harvested by soft aspiration as to reduce adipocyte trauma and using a syringe fitted with a 3.5mm cannula. After centrifugation, fat was reinjected retrogradely and by making thin cylinders of fat similar to "spaghetti". Moderate to severe asymmetry is one of the best indications for lipomodeling using one or two sessions. Thus, a perfect and lasting symmetry is achieved, without the need of an implant, which would inevitably leads to asymmetry because of a dissimilar evolution of the breast all over the time. In Becker's nevus syndrome, lipomodeling has also been performant in bluring the hyperpigmentation of the nevus. The role of lipomodeling in pectus excavatum deformity (antero-posterior sternocostal depression) is also crucial. Lipomodeling can be used alone, or in combination with a rigid customed silicone implant. Tuberous breasts include various anomalies. Lipomodeling is currently used especially when the anomaly is unilateral (2 fat graft sessions are usually needed). Fasciotomies are frequently performed too. Lipomodeling is a real revolution in the management of Poland syndrome (anomaly characterized by the unilateral lack of the pectoralis major muscle, more or less associated with other ipsilateral anomalies). On average, 3 to 5 sessions are necessary to obtain a suitable symmetry. Lipomodeling is very unlikely to cause major surgical complications. Cytosteatonecrosis nodules mainly occur with novice practitioner and decrease as they become more experienced. However, the principle of the three-dimensional network, and the phenomenon of tissue saturation of the recipient site should be respected. The main limitation of lipomodeling is directly related to the amount of fat available. That's why it is very important to evaluate it during the first clinical consultation, and to carefully select the patients eligible in order to limit the risk of failure. Lipomodeling of congenital breast anomalies is a technique well established, with a precise algorithm to follow, and is a procedure with low surgical risk, less scarring, cosmetic and lasting results. This technique is to be suggested as a first line treatment in all indications of congenital breast deformities, alone or combined to an implant. Therefore, it seems essential that a plastic surgeon fully master the indications and the use of fat tissue transfer procedure, in order to obtain natural and harmonious results.

The Palpable Nodule After Autologous Fat Grafting: Distinguishing Benign Versus Malignant Lesions in a Breast Reconstruction Cohort

BACKGROUND

Nodule formation after autologous fat grafting (AFG) to the breast is the most common complication. In the reconstructive population, this generates significant patient anxiety and presents a diagnostic challenge. We characterized palpable nodule occurrence after AFG in breast reconstruction and compared benign versus malignant nodule characteristics.

METHODS

Chart review of the senior author's experience with breast fat grafting was performed. Data extracted included demographics, intra-operative details, nodule data, radiographic characteristics and biopsy results. Logistic regression identified risk factors for nodule formation. Unpaired t-tests and Fisher's exact tests compared characteristics of benign versus malignant nodules.

RESULTS

In total, 7 75 breasts were identified that underwent 1,158 fat grafting procedures, of which 67 (8.6%) developed palpable nodules. Sonographic characterization of nodules included presumed fat necrosis (38.2%), benign lesion (27.6%), presumed oil cysts (17.1%), indeterminate (8.9%) and concerning for malignancy (8.1%). Lesions concerning for malignancy were more often irregular (10.0% versus 0-2.9% of benign nodules) and more often larger than 0.8 cm in greatest dimension (80% versus 42.9%-61.8% of benign nodules). Six patients developed a palpable local recurrence. Malignant nodules tended to be larger (1.45 cm versus 0.70 cm, p=0.03), were more often vascular (50% versus 3.8%, p=0.03) and tended to occur later (17.5 months versus 10.0 months, p=0.60). Benign nodules occurred in the setting of larger fat graft volumes (64.2 cc versus 40.0 cc, p=0.008).

CONCLUSION

This study provides the first comparison of radiographic and clinical characteristics between benign and malignant palpable nodules post-AFG in breast reconstruction.

Optimizing Surgical Outcomes with Small-Volume Silicone Implants Associated with Autogenous Fat Grafting in Primary and Revision Breast Augmentation Surgery: Soft Weight Hybrid (SWEH) Concept

BACKGROUND

Simultaneous association of autologous fat grafting (AFG) with silicone implants, defined as a hybrid procedure, has been proposed for breast augmentation (BA). In some patients, larger-volume implants may result in larger incisions, with long-term effects including implant palpability, soft tissue atrophy, and secondary ptosis. Some patients do not want large volume implants, or have insufficient soft tissue coverage. Recent improvements in AFG have led to new surgical options in BA for addressing these cases.

OBJECTIVES

This study combines AFG in BA using small-volume implants, known as the SWEH (soft weight hybrid) approach, and evaluates aesthetic advantages and outcomes following primary/secondary BA.

METHODS

25 patients (50 breasts) underwent SWEH procedures; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant and patients refused large-volume implants. Three-dimensional images were obtained using a Divina 3D scanner system (AX3 Technologies, Miami, USA) to assess breast volume (BV) and intermammary distance (IMD) during follow-up.

RESULTS

Mean patient age was 29.3 years (range: 21-42) and mean body mass index was 19.3 kg/m² (15.3-27.2). The most common implant (SmoothSilk surface Round/Ergonomix style) volume was 180 cc (175-215), and patients received a mean volume of 125 cc of fat (89-168)/breast in the subcutaneous tissue. Preoperative average BV measurements were 236.85 cc (170-335). At 3 and 12 months post-procedure, the average BV values were 488.82 and 478.73cc, respectively (p=0.475). The average preoperative IMD was 31.76 mm (range, 22-43); at 3 and 12 months post-procedure, the average IMD was 20.47 and 20.94 mm, respectively (p=0.61). Postoperative complications included subcutaneous banding in the axilla (n = 1; 4%) and hypertrophic scarring (n = 1; 4%). Breast imaging exams were performed; in 2 breasts (8%) localized oil cysts were observed; no cases of suspicious calcifications, fat necrosis, or lumps were seen. Fat retention rate (1 year) was calculated by the difference between the BV expected with 100% fat intake and the real BV observed. In our sample we observed an average of 72.7 (range: 69.2-77.3, SD: 2.63) and 76.7 (range: 72.3-79.9, SD: 2.18) percent of fat intake on the right and the left breast respectively. No rippling, implant malposition, or infection was observed during a mean follow-up of 22 months (6-40).

CONCLUSIONS

SWEH is a useful surgical alternative that combines the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of larger-volume implants. The association of small-volume gel implants and smaller scars can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Injected Breast Materials: Review of Imaging Features and Characteristics

In the United States, silicone and saline breast implants with their familiar radiologic appearance are the mainstays of breast augmentation. However, less well-known sequelae of unconventional injected materials introduced for cosmetic and noncosmetic purposes may also be encountered on breast imaging-for example, free silicone, paraffin and/or oil, polyacrylamide gel, autologous fat, and hyaluronic acid, which are encountered in the setting of breast augmentation. Breast injection of go-yak is not cosmetic but also results in characteristic imaging findings. Breast changes due to extravasation of chemotherapy or interstitial brachytherapy can mimic the appearance of injected noncosmetic materials. Because many of these materials can mimic or obscure imaging findings of breast cancer, it is important to recognize their varied appearances and the limitations of imaging alone in delineating breast injection material from cancer. Given the relatively uncommon incidence of injected materials into the breast, this article aims to review the imaging appearance in order to aid radiologists in maximizing cancer detection and ensuring optimal patient management.

Hybrid Implant and Grafted Fat Breast Augmentation: Designing the Pathway to a Future With Breasts Free of Silicone Breast Implants

BACKGROUND

Fat grafting in breast augmentation surgery is becoming increasingly popular, allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one of the current issues surrounding fat grafting is the lack of standardization.

OBJECTIVES

The objective of this study was to validate and summarize expert-based advice to help plastic surgeons better understand the benefits of utilizing fat grating to reduce implant size in their surgical planning.

METHODS

This was a prospective study of fat grafting in 56 patients who underwent fat transfer together with silicone breast implants. A 3-dimensional planning system was used to plan the procedure and also to analyze the fat retention and resorption rates. Pictures served as a basis for a questionnaire in which both patients and physicians were asked to rate their satisfaction.

RESULTS

Patients reported a satisfaction rate of "excellent" in 83.3% of cases and "good" in 16.7%. Physician satisfaction was rated as "excellent" in 84.5% of cases, "good" in 13.3%, and "fair" in 4.2% of cases. The mean fat volume grafted per breast was 113.63 mL. The mean absorption rate was 4.53%.

CONCLUSIONS

The procedure presented consistent and reproducible results. Hybrid breast augmentation can help design a pathway for a future with breasts free of silicone. This information is particularly relevant for women who have their first breast augmentation at an early age and will probably have 2 to 5 additional surgeries in their lifetime due to the nature of current silicone breast technology.

LEVEL OF EVIDENCE: 4

[Diagnosis and management of fat necrosis after autologous fat transplantation of breast]

Objective

To review the diagnosis and management of fat necrosis after autologous fat transplantation of breast.

Methods

Based on the latest related literature, the pathology, clinical and radiographic examinations, influence factors, as well as the management of fat necrosis after autologous fat transplantation for breast augmentation and reconstruction were summarized.

Results

Fat necrosis after breast autologous fat transplantation is histologically manifested as hyaline degeneration, fibrosis, and calcification. The diagnosis of fat necrosis includes clinical examination, imaging examination (ultrasound, mammography, and MRI), and biopsy. The occurrence of fat necrosis is closely related to patient's own reason and fat transplantation technology. Optimizing the process of fat acquisition, purification, and transplantation can reduce the occurrence of fat necrosis. Intervention or not after fat necrosis depends on the nature of the nodules. According to the nature of the the nodules, various methods such as simple aspiration, vibration amplification of sound energy at resonance liposuction, or direct excision can be selected.

Conclusion

Fat necrosis after autologous fat transplantation of breast are difficult to control. How to process fat to minimize the injury and maximize the activity of grafted fat needs further researches.

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

BACKGROUND

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA.

OBJECTIVES

The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA.

METHODS

In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant.

RESULTS

Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months).

CONCLUSIONS

SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Oncologic Safety of Autologous Fat Grafting in Breast Reconstruction

Autologous fat grafting is a useful adjunct to breast reconstruction to address contour changes, volume loss, and deformity. More recent benefits observed include mitigation of pain and inflammation. Although there is no clinical evidence to suggest an increased risk in recurrence or new cancer development in fat grafting for breast reconstruction, the oncologic safety of grafting has come into question. Adipose tissue grafts contain progenitor cells and immunomodulatory cytokines, which may induce vasculogenesis or tumor progression or recurrence at the site. Although these are all theoretical concerns, there is a discrepancy between basic science research and clinical outcomes studies. In this review, the authors summarize available literature regarding three important controversies in fat grafting for oncologic breast reconstruction: the interaction of graft component cells, such as adipose-derived stem cells, with cancer cells; the concern of fat grafting interference with breast cancer screening and detection; and clinical evidence regarding the oncologic safety of fat grafting following breast cancer treatment.

Autologous fat grafting in breast reconstruction: implications for follow-up and surveillance

The procedural volume of autologous fat grafting (AFG) has risen over the past several years, specifically in the setting of breast reconstruction, despite controversy surrounding its oncologic safety. While some in vitro and animal models have cast doubt on the oncologic safety of AFG, there is no clinical evidence that AFG in breast reconstruction is associated with an increased risk of cancer development or recurrence or an inability to adequately assess changes in the breast. That being said, recommendations regarding surveillance and follow-up after AFG in breast reconstruction are largely surgeon directed and differ across practices. The purpose of this review is to summarize the current literature and provide evidence-based recommendations.

Surgical Management of the Explant Patient: An Update on Options for Breast Contouring and Volume Restoration

BACKGROUND

Breast implant removal is becoming a common procedure in light of the current events and controversies with silicone breast implants. The authors believe strongly in informing patients about the indications and options regarding both explantation and the management of the secondary breast deformity.

METHODS

Relevant literature regarding the management of the explant patient was reviewed and organized to provide an update on prior publications addressing the explant patient population.

RESULTS

Surgical management options after implant removal include breast contouring and volume restoration. Fat augmentation has been used in both aesthetic and reconstructive breast surgery.

CONCLUSIONS

The authors review the surgical management for explantation, breast contouring, and autologous fat grafting for volume restoration. In the explant patient, autologous fat grafting serves as a reliable option for volume restoration.

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

BACKGROUND

Autologous fat grafting is a useful adjunct following breast reconstruction. The impact of autologous fat grafting on oncologic safety and surveillance remains questionable, particularly following breast conservation therapy.

METHODS

The authors performed a retrospective review of patients who underwent delayed fat grafting following breast conservation therapy between 2006 and 2016. A control group of conservatively managed patients without grafting was matched for cancer stage, age, body mass index, and follow-up. Outcomes included locoregional recurrence and oncologic surveillance.

RESULTS

Seventy-two patients were identified per cohort. There were no differences in median age (50 years versus 51 years; p = 0.87), body mass index (28.2 kg/m versus 27.2 kg/m; p = 0.38), or length of follow-up (61.9 months versus 66.8 months; p = 0.144) between controls and grafted patients, respectively. Overall, four patients in each cohort experienced recurrence (5.6 percent; p = 1.00) with similar cumulative incidence estimates observed (log-rank test, p = 0.534). There were no significant differences in palpable mass (9.7 percent versus 19.4 percent; p = 0.1), fat necrosis (34.7 percent versus 33.3 percent; p = 0.86), calcifications (37.5 percent versus 34.7 percent; p = 0.73), or indication for breast biopsy (15.3 percent versus 22.2 percent; p = 0.23) between breast conservation and breast conservation therapy plus autologous fat grafting cohorts, respectively.

CONCLUSIONS

Overall, the authors found no difference in recurrence rates after breast conservation with or without delayed fat grafting. Furthermore, there were no differences in the rates of fat necrosis, palpable mass, and abnormal radiographic findings. This study represents the longest follow-up to date in in a large matched study of autologous fat grafting with breast conservation therapy demonstrating oncologic safety and no interference with follow-up surveillance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Silicone Implant Versus Silicone Implant Assisted by Stromal Enriched Lipograft Breast Augmentation: A Prospective Comparative Study

Background: Implant-assisted breast augmentation is among the most performed surgeries performed by plastic surgeons today. This prospective study evaluated the patient satisfaction and complication rates using high-profile round silicone implant alone (traditional breast augmentation) Group A versus the high-profile round silicone implant assisted with stromal enriched lipograft (composite breast augmentation) Group B. Methods: A total of 50 female patient candidates to undergo breast augmentation between January to September 2017 were randomly assigned to either group. The periareolar technique for breast augmentation and the subfascial plane were used in both groups for the insertion of the high-profile round silicone implants. The stromal enriched lipograft (SEL) was used in Group B for the preparation of the autologous fat grafting to the breast. The satisfaction of each patient with body appearance following breast augmentation was rated using an already published scale of 1–5. The rate of complications was analysed. Results: AS performed all the surgeries. In Group A, the age range was between 19 and 48 years (mean of 22.5 years). In Group B, the age range was between 20 and 47 years (mean of 24.1 years). The average BMI of Group A was 24 m/kg² and 23 m/kg² of Group B. Patient satisfaction meta-analysis for Group A and B at 12 months shows that patients in Group B expressed a satisfaction that is superior when compared to Group A patients. The ability to camouflage the implant could explain the higher satisfaction rates in Group B. The rate of complications appears similar in both groups. Conclusions: Composite breast augmentation using a combination of round high-profile implants and SEL in breast augmentation can achieve a higher patient satisfaction and aesthetic outcome as compared to the round high-profile breast augmentation alone. The technique is safe, simple and fast with low complication rates. Large multicentre, controlled, prospective studies need to be performed to further confirm the favourable results that were observed in this study.

Oncologic safety of immediate autologous fat grafting for reconstruction in breast-conserving surgery

IMPORTANCE

Autologous fat grafting (AFG), or lipofilling, has been used for immediate reconstruction at the time of breast-conserving surgery in order to achieve a satisfactory cosmetic outcome in patients with breast cancer and an unfavorable tumor-to-breast volume ratio or unfavorable tumor location. However, the oncologic safety of this technique is still unclear.

OBJECTIVE

To determine whether AFG performed simultaneously with breast-conserving surgery is associated with differences in local relapse rates and disease-free survival.

DESIGN

Matched retrospective cohort study.

SETTING

Tertiary referral center.

PARTICIPANTS

Patients undergoing breast-conserving surgery with or without AFG between 2004 and 2016 were retrospectively enrolled and matched for age, staging, grade, tumor histology, and tumor immunohistochemical profile.

MAIN OUTCOME(S) AND MEASURE(S)

The cumulative incidence of locoregional recurrence (LRR) and disease-free survival were the primary end points, while distant recurrence and overall survival were the secondary end points.

RESULTS

A total of 320 patients were followed. Cases were matched with controls at a 1:4 ratio. There was no difference in LRR or distant recurrence of breast cancer between the two groups. The annual LRR rate was 0.86% in patients who received immediate AFG vs. 0.7% in patients undergoing breast-conserving surgery alone (p ≥ 0.05). Number of lymph nodes was the sole independent risk factor for local recurrence (p = 0.045). No significant differences in disease-free survival rates were found between the groups.

CONCLUSIONS AND RELEVANCE

At a mean follow-up of 5 years, no significant differences in locoregional recurrence rates were found between patients who received immediate AFG and those who underwent breast-conserving surgery alone. These findings corroborate previous research demonstrating the oncological safety of immediate AFG reconstruction, further suggesting that this technique as a safe, effective way to achieve optimal cosmetic outcomes in primary breast cancer surgery without jeopardizing oncologic outcomes.

Locally Increased Level of Inorganic Phosphate Induced Nodules or Calcification After Bolus Fat Grafting

BACKGROUND

Nodules or calcifications have been a common complication after breast augmentation with fat grafting, especially in cases with partial bolus fat grafting. There are some clinical preventive measures, but mechanisms related to this complication have not been elucidated yet. Inorganic phosphate (PI), being a product of fat metabolism, is a well-known stimulus of other kinds of pathological calcification such as vascular calcification. We aimed to determine whether PI had a similar effect on formation of nodules after fat grafting.

METHODS

Nodules or calcification after fat grafting models using nude mice were created by bolus fat injection. Levels of PI of necrotic liquid located in the central zone and mineralization deposition of graft were examined 1 week, 2 weeks, 1 month, 2 months and 7 months after bolus fat injection. External high phosphate solution was injected 3 times a week to the fat grafts for 2 months, and mineral deposition was examined. In addition, adipose-derived stem cells (ADSCs) were treated with high phosphate osteogenic differentiation medium in various concentrations and times. ADSCs were also treated with osteogenic differentiation in addition to tetramisole which could reduce the level of PI. Mineral depositions of the cells were examined. The central necrotic liquid was extracted from patients who found palpable nodules after breast augmentation with fat grafting. The level of PI of this necrotic liquid and normal lipoaspirates from patients who received normal liposuction for body contouring was compared.

RESULTS

The in vivo study indicated that the local PI concentration of the necrotic zone increased significantly 2 months after large volume bolus fat injection. Calcification was not formed after 2 months, but was formed after 7 months, indicating that the effect of PI on calcification was time-dependent. In addition, with the effect of external injection of high phosphate solution into the fat graft, calcification was formed after 2 months, indicating the effect of PI on calcification was dose-dependent. The in vitro study also indicated PI could induce calcification of ADSC in a time- and dose-dependent manner. The study in humans indicated that the level of PI in the necrotic zone of nodules after fat grafting was higher than that in normal lipoaspirates.

CONCLUSIONS

This study indicated that the level of PI in the central necrotic zone was elevated after bolus fat injection, which could provide an environment to induce calcification of surrounding tissue.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The use of autologous fat grafts in breast surgery: A literature review

Autologous fat injection was first described roughly a century ago and has been used in surgery ever since. In addition to its use in many surgical fields, it is also frequently used for both aesthetic and reconstructive purposes in breast surgery. Since the application of fat grafting in breast surgery has steadily increased, studies investigating its reliability have simultaneously become increasingly common. Previous studies have reported that the use of fat grafting in breast surgery is reliable, but some pending questions remain about its routine use. In order to use fat grafts successfully in breast surgery, it is necessary to be familiar with the structure and content of adipose tissue, the efficacy of adipose stem cell-enriched fat grafts, the oncological safety of fat grafts, and the problems that may occur in the radiological follow-up of patients who undergo fat grafting procedures. In this literature review, we aim to discuss the use of fat grafts in breast surgery by investigating these common problems.

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

BACKGROUND

Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors' aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process.

METHODS

A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting.

RESULTS

From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years.

CONCLUSIONS

Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

International Expert Panel Consensus on Fat Grafting of the Breast

Background

Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018).

Methods

All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting.

Results

The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements.

Conclusions

The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Does lipofilling after oncologic breast surgery increase the amount of suspicious imaging and required biopsies?-A systematic meta-analysis

OBJECTIVE

The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings.

METHODS

We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast.

RESULTS

Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8 months (range 6-50 months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%.

CONCLUSION

Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

Principles and Applications of Fat Grafting in Plastic Surgery

Autologous fat transplantation has become increasingly popular in recent years. Its biocompatable properties and availability made it a widely used treatment modality for soft tissue augmentation and volume replacement in both reconstructive and aesthetic plastic surgery. Multiple protocols and clinical applications have been described in the literature, with wide variations in the harvesting, processing, and injection techniques. In this review, the authors will discuss the basic principles and clinical applications of fat grafting in plastic and reconstructive surgery. The article will then conclude with a discussion of fat grafting limitations as well as potential future applications, giving the reader a well-rounded understanding of autologous fat transfer.

Adipose-Derived Stem Cells in Aesthetic Surgery

Adipose-derived stem cells (ADSC) have come to be viewed as a ubiquitous solution for aesthetic and reconstructive problems involving loss of tissue volume and age or radiation-induced loss of tissue pliability and vascularity. As the theoretical potential of "stem cell therapy" has captured the public imagination, so the commercial potential of novel therapies is being exploited beyond scientifically sound, hypothesis-driven paradigms and in the absence of evidence establishing clinical efficacy and safety. Moreover, with variations in methods of isolation, manipulation, and reintroduction described, it is unclear how the practitioner with an interest in ADSC can harness the clinical potential in reproducible and scientifically measurable ways. This Continuing Medical Education (CME) article presents a summary of our understanding of what ADSC are, their utility within the field of aesthetic surgery, and the current and future directions for adipose stem cell research.

Recent Advances on Relationship Between Inorganic Phosphate and Pathologic Calcification: Is Calcification After Breast Augmentation with Fat Grafting Correlated with Locally Increased Concentration of Inorganic Phosphate?

BACKGROUND

Pathologic calcification has frequently occurred after breast augmentation with fat grafting as well as other conditions such as breast cancer, trauma, myocardial infarction, arteriosclerosis and even after reduction mammoplasty. Inorganic phosphate, correlated with fat metabolism, is an important factor that induces pathologic calcification such as vascular calcification.

METHODS

A literature search was conducted using PubMed with the keywords: calcification, inorganic phosphate, fat. Studies related to the process of pathologic calcification, correlation between inorganic phosphate and pathologic calcification, between inorganic phosphate and fat metabolism in pathologic calcification were collected.

RESULTS

Various mechanisms were referred to in pathologic calcification among which inorganic phosphate played an important role. Inorganic phosphate could be liberated, under the effect of various enzymes, in the process of fat metabolism. The authors hypothesized that a large-scale necrotizing zone, which could occur in fat grafting with large amounts per cannula, might provide a high-phosphate environment which might contribute to differentiation of surrounding cells such as stem cells or regenerated vessel cells into osteoblast-like cells that induce pathologic calcification.

CONCLUSION

Inorganic phosphate, which was correlated with fat metabolism, played a significant role in pathologic calcification. We firstly hypothesize that calcification after fat grafting may be related to locally increasing concentrations of phosphate in a necrotizing zone. Further research should be conducted to verify this hypothesis.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Breast imaging for aesthetic surgery: British Society of Breast Radiology (BSBR), Association of Breast Surgery Great Britain & Ireland (ABS), British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS)

This is an overview of the guidelines for breast imaging before and after aesthetic (cosmetic) breast surgery, which includes but is not limited to implants, lipomodelling and mammoplasty procedures. The guidelines are based on a review of the literature and consensus of breast imaging and aesthetic breast surgery specialists. 1. Pre-aesthetic surgery 2. Post-aesthetic surgery If breast imaging or breast assessment is required, it should be performed in a designated breast facility with access to specialist breast imaging and a complete breast multidisciplinary team in accordance with national guidelines and recommendations.

Immediate reconstruction with autologous fat grafting: influence in breast cancerregional recurrence

Objective

to evaluate local and systemic recurrence of breast cancer in patients submitted to autologous fat grafting in the immediate reconstruction after conservative surgery for breast cancer.

Methods

this is a historical cohort study comparing 167 patients submitted to conservative surgery without reconstruction (conservative surgery group) with 27 patients submitted to conservative treatment with immediate graft reconstruction, following the Coleman's technique (lipofilling group). All patients had invasive carcinoma and were operated by a single surgeon from 2004 to 2011. The postoperative follow-up time was 36 months.

Results

the overall incidence of local recurrence was 2.4%. No patient in the lipofilling group had local recurrence during the study period. For systemic recurrence, the rates obtained were 3.7% (one patient) for the fat grafting group and 1.8% (three patients) for the conservative surgery group without reconstruction.

Conclusion

there was no significant difference for local or systemic recurrence in the groups studied. Immediate autologous fat grafting appears to be a safe procedure.

Latissimus Dorsi and Immediate Fat Transfer (LIFT) for Complete Autologous Breast Reconstruction

Supplemental Digital Content is available in the text.

Background:

Despite the popularity of latissimus dorsi (LD) flap in breast reconstruction, a breast implant is often necessary to achieve sufficient volume. Prior reports describe fat grafting to the LD flap as a secondary procedure to correct contour deformities and improve volume. Our institution has instituted autologous breast reconstruction with an LD flap and immediate fat transfer (LIFT).

Methods:

A retrospective review of all patients undergoing the LIFT procedure was undertaken. Patient age, total volume of fat transfer, length of follow-up, need for adjuvant therapy, and complications were recorded. The procedure begins with harvest of the LD flap and fat. Prior to disorigination of the latissimus muscle, fat is injected into the flap. Flap harvest is then completed and inset to create a breast mound.

Results:

Eighteen patients underwent LIFT procedures over 3 years with an average follow-up of 8.7 months (range, 2–24). Four breasts (22.2%) had previously received adjuvant radiation therapy. The mean total fat grafting volume was 515.5 mL (range, 325–730) per breast. The average estimated fat graft take was 66.8% (range, 50–80%). Four patients (22.2%) experienced complications.

Conclusion:

Autologous augmentation of the LD flap with lipotransfer has been used to avoid placement of an implant. We improve the technique by performing lipotransfer during index reconstruction. Furthermore, we perform lipotransfer prior to disorigination of the LD muscle to minimize trauma to the flap and increase the efficiency of fat grafting. Our experience demonstrates that this technique is a viable autologous alternative to microsurgical breast reconstruction.

Complications of Fat Transfer for Breast Augmentation

Autologous fat grafting is quite common for breast augmentations as well as for reconstructive breast surgery. Coleman has described the surgical technique of fat grafting. Fat is harvested, and after centrifugation and refinement, blunt infiltration cannulas are used to place the fat through small incisions. The grafted tissue is placed in small aliquots with each withdrawal of the cannula. In order to achieve an aesthetically pleasing contour of the breast, the fat should be layered into different levels from the chest wall to the skin. However, autogenous lipotransfer if not performed lege artis might lead to complications such as fat necrosis, calcification, formation of encapsulated fatty masses (cystic lesions), lymphadenopathy, disfigurement of breast contouring, hypersensitive breasts, itchy nipples. A 36-year old female patient, presented with multiple palpable cystic lesions, disrupted breast contouring, asymmetry, hypersensation and pain during examination, 6 months after autologous fat grafting for breast augmentation elsewhere. The patient had ultrasound and MRI screening, which revealed the multiple bilateral cysts formation in the breast tissue. Surgical removal of the large lesions was performed, and specimens were sent for pathology and cytology consideration and screening. A few months after surgical removal of these lesions and after symptoms subsided, breast augmentation was performed with silicone implants. An aesthetically pleasing result together with relief of the patient's initial symptomatology was achieved. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Procedure, applications, and outcomes of autologous fat grafting

OBJECTIVE

To systematically review the procedure, applications, and outcomes of autologous fat grafting, a promising technique with various clinical applications.

PATIENTS AND METHODS

Literature review of publications concerning autologous fat grafting.

RESULTS

Since its introduction, lipofilling has become increasingly popular; however, its results are variable and unpredictable. Several modifications have been made to the procedures of fat harvesting, processing, and injecting. Surgical excision and low negative-pressure aspiration with large-bore cannulas minimize adipocyte damage during fat harvesting. The "wet" method of fat harvesting involves fluid injection at the donor site and facilitates lipoaspiration while minimizing pain and ecchymosis. For fat processing, centrifugation at a low speed is preferable to high-speed centrifugation, gravity separation or filtration. Fat injection at the recipient site should be performed using small-gauge cannulas in a fanning out pattern over multiple sessions, rather than a single session. Fat grafts exhibit not only dermal filler properties but also regenerative potential owing to the presence of stem cells in fat tissue. Thus, the clinical applications of autologous fat grafting include correction of secondary contour defects after breast reconstruction, release of painful scar contractures, and treatment of burn scars and radiodermatitis. Lipofilling is also used in aesthetic surgery, such as facial and hand rejuvenation, augmentation rhinoplasty, and breast and gluteal augmentation. The complications of lipofilling are minimal and include bruising, swelling, pain, infection, necrosis, and calcification.

CONCLUSIONS

Lipofilling is a low-risk procedure that can be used to correct soft-tissue defects in the face, trunk, and extremities, with minimal discomfort for patients.

Autologous Fat Transplantation to the Reconstructed Breast Does not Hinder Assessment of Mammography and Ultrasound: A Cohort Study

BACKGROUND

Autologous fat transplantation (AFT) to the breast can correct defects and be a part of a breast reconstruction to achieve a better aesthetic result. The impact of AFT on the radiological evaluation and detection of cancer remains unclarified. The aim of this study is to investigate whether AFT induces lasting modifications.

METHODS

In the present study, a valuation was performed of 44 breasts from 37 patients examined with mammography and ultrasound before and after autologous fat transplantation. Breast radiologists evaluated the images using a study specific protocol.

RESULTS

AFT did not hinder post-operative assessment of mammograms or ultrasound. No detectable changes with serious clinical impact were found after injections of mean 177 ml (34-516) of fat in one to four sessions. The rate of oil cysts was significantly higher after AFT than pre-operatively (2.3 vs. 34.1 % p = 0.0013). Significantly more post-operative oil cysts were detected after injection of larger volumes of fat (144 vs. 243 ml, p = 0.013). No significant differences were found in the post-operative images regarding age at surgery, follow-up time, or time from previous breast surgery.

CONCLUSION

AFT does not impair assessment of mammograms and ultrasound in patients who have a history of breast cancer surgery or prophylactic mastectomy.

Fat Grafting with Tissue Liquefaction Technology as an Adjunct to Breast Reconstruction

Background

Tissue liquefaction technology (TLT) delivers warmed saline from the liposuction cannula tip at low pressure pulses to disaggregate adipocytes. This technology differs significantly from that used in other liposuction devices including water jet-assisted liposuction. Here we introduce our early experience with this technology in the setting of fat transfer for revision breast reconstruction.

Methods

A retrospective chart review of 136 consecutive patients who underwent fat harvest with TLT and subsequent transfer into 237 breast reconstructions was conducted at a single institution. This two-surgeon series examined donor and recipient site complication rates over a median follow-up of 143 days [87–233].

Results

The overall complication rate was 28.7 %, of which the majority (22.1 %) was fat necrosis at the recipient site as documented by any clinical, imaging, or pathologic evidence. The abdomen served as the donor site for half of the cases. Donor site complications were limited to widespread ecchymosis of the donor site notable in 10.4 % of cases. Twenty-five percent of patients had received postmastectomy radiotherapy prior to fat transfer. Prior to revision with fat transfer, implant-based breast reconstruction was used in 75.5 % of cases, and autologous flaps in the remainder. Fat transfer was combined with other reconstructive procedures 94.1 % of the time.

Conclusions

TLT can be used to harvest adipocytes for fat transfer with donor site morbidity and recipient site complications comparable to other modalities. The efficiency and quality of harvested fat makes this technology appealing for wide spread adoption during fat transfer.

Level of Evidence IV

This journal requires that the authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Autologous fat transplantation for breast reconstruction: A literature review

INTRODUCTION

The use of autologous fat transplantation to correct volume and contour defects, scars, and asymmetry after breast cancer surgery has increased over the past 20 years. Many developments and refinements in this technique have taken place in recent years, and several studies of the safety of lipofilling in the breast have been published.

PRESENTATION OF CASE

We performed a literature review of this technique, highlighting the crucial role of lipofilling in breast cancer reconstruction.

DISCUSSION

The efficacy of the fat graft transplantation depends on the experience and the technique used by the surgeon. The ASCs (adipose-derived stem cells) contained in the fat graft has proven to be crucial for breast reconstruction by mean the regeneration of tissue, through the chemotactic, paracrine, and immunomodulatory activities and their in situ differentiation.

CONCLUSION

The role of lipofilling for breast reconstruction could be more significant with the application of the findings of experimental research on tissue engineering and ASCs.

Autologous fat transfer to the subcutaneous tissue in the context of breast reconstructive procedures

Autologous fat transfer (AFT) is an appropriate technique for aesthetic rejuvenation of the face, aesthetic enhancement of hands, correction of the facial appearance in various disorders and constitutes a surgical alternative of treatment of numerous breast deformities ranging from distorting posttraumatic scars, post-eczema lesions, post-burn deformities to partial or total breast reconstruction. Our work is aimed to familiarize dermatologists with the technique of harvesting and implanting the aspirate of adipose cells in patients consulted for deformities of the breast. In addition, the review summarizes the most common applications of AFT in the breast reconstructive procedures. In summary, AFT is an oncologically safe, relatively complication-free, minimally invasive surgical technique, which can be used to correct a wide range of deformities, which are commonly seen by dermatologists, in the area of the face, trunk and extremities. The procedure can correct a wide range of breast deformities, from contour or single quadrant deformities up to the state after mastectomy.

Autologous Fat Grafting in Cosmetic Breast Augmentation: A Systematic Review on Radiological Safety, Complications, Volume Retention, and Patient/Surgeon Satisfaction

BACKGROUND

Autologous fat grafting (AFG) is increasingly used in cosmetic surgery. However, its efficacy and safety are still ambiguous. Both a comprehensive overview and recapitulation of the relevant literature provide current evidence on the efficacy and outcomes of AFG in cosmetic breast surgery.

OBJECTIVES

This review provides an up-to-date overview of the literature on AFG in cosmetic breast augmentation.

METHODS

A systematic review of the literature on AFG used for cosmetic breast augmentation was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. This study included selected studies that were published between January 1996 and February 2016 and reported on 10 patients or more who had a minimal mean follow-up period of 1 year.

RESULTS

In this study, 22 articles that reported on 3565 patients with follow-up periods ranging from 12 to 136 months were included. A complication rate of 17.2% (95% CI 15.9-18.5) was seen. Indurations were the most frequent complication (33.3%, 95% CI 20.4-46.3), followed by persistent pain (25%, 95% CI 0.5-49.5), and hematoma (16.4%, 95% CI 14.5-18.4). Mammograms revealed micro-calcifications (9.0%, 95% CI 6.4-11.5) and macro-calcifications (7.0%, 95% CI 3.8-10.2). The mean volume retention was 62.4% (range, 44.7-82.6%), with a satisfaction rate of 92% in patients and 89% in surgeons.

CONCLUSIONS

AFG is a promising method in achieving autologous cosmetic breast augmentation with satisfactory volume retention and satisfaction rates in eight and six studies, respectively. Complications and radiological findings are comparable to those after implant augmentation. Future studies should focus on cancer occurrence and detection to further substantiate AFG safety. In addition, grafting methods and the use of auxiliary procedures to identify factors leading to better outcomes in terms of volume retention should be investigated. Finally, objective questionnaires are needed to represent patient satisfaction.

LEVEL OF EVIDENCE

3 Therapeutic.

The Safety, Effectiveness, and Efficiency of Autologous Fat Grafting in Breast Surgery

Background:

For years, the safety and effectiveness of autologous fat grafting (AFG) for breast reconstruction have been in question, with particular concern over fat necrosis, calcifications, cyst formation, and interfering with the detection of breast cancer. However, increasing evidence suggests that the complication rates and clinical results are generally acceptable to both clinicians and patients. The emerging challenge is the numerous AFG techniques and systems, where there are limited knowledge and data. The objective of this study was to conduct a literature review that focuses on the safety, effectiveness, and efficiency of various AFG techniques as applied to the breast.

Methods:

A PubMed search using terms related to AFG was performed over a 5-year period (April 1, 2010–April 30, 2015). Original articles focused on AFG to the breast, with outcomes on safety, effectiveness, and efficiency, were included.

Results:

Five hundred ninety-eight articles were identified with 36 articles included (n = 4306 patients). Satisfaction rates were high although the prevalence of complications was low—similar to previous findings. Seven studies reported average operating room time with an overall mean of 125 minutes (range: 40–210). The mean volume of fat harvested was 558 mL (range: 120–1299), and fat injected was 145 mL (range: 20–607). A positive association between injection volume and operating time was observed.

Conclusions:

This review validates previous findings on the safety and effectiveness of AFG to the breast and highlights its efficiency. The efficiency data available, although limited, suggest that there is an opportunity to achieve time and cost savings while not sacrificing safety and effectiveness.

An Overview of Fat Grafting

The use of autologous fat grafting for a wide variety of clinical applications has increased dramatically over the past few decades. The article provides an overview of the technique, a historic background, and briefly explores some of the current ways in which fat grafting is being used in plastic surgery.